Gaps in Pediatric Obesity Treatment Need Attention, Especially From an Equity Perspective

The U.S. Preventive Services Task Force updated its recommendations for treatment of pediatric obesity. The task force reviews scientific research and makes evidence-based recommendations for all areas of primary care.

Since their last update to pediatric obesity recommendations in 2017, the landscape of obesity treatment has changed dramatically, particularly with the introduction of weight loss drugs such as semaglutide (Wegovy) and liraglutide (Saxenda), which the FDA has approved to treat obesity in adolescents 12 and older. Obesity rates have also risen, with nearly 20 percent of children and teens now meeting the threshold for the medical definition of obesity.

Thomas Robinson, MD, the Irving Schulman, MD, Endowed Professor of Child Health and professor of pediatrics and of medicine, developed the Pediatric Weight Control Program at Stanford Medicine Children’s Health in the 1990s, has conducted decades of research on childhood and adolescent obesity and was following the updated recommendations closely.

He was invited to write an editorial for the Journal of the American Medical Association to accompany the new guidelines, outlining what treatments got the top recommendation, and how gaps in the healthcare system make access to the best treatments inequitable. Robinson took the time to go over those key points and emphasize what needs to be done next. This interview has been edited for clarity and length.

What are the best evidence-based approaches for treating pediatric obesity, according to the US Preventive Services Task Force?

From their review of behavioral treatment of obesity, the only treatments that consistently showed benefits are what they call comprehensive, intensive behavioral interventions. Our Pediatric Weight Control Program at Stanford Medicine Children’s Health is an example and has had a great success rate for the last 25 years. They recommend these types of programs as the mainstay of pediatric obesity treatment.

The Task Force looked at programs aimed at kids age 6 to 19, and gave a “B” grade to the scientific evidence for these programs, which is the same level of recommendation they issued in 2010 and 2017. (The task force uses letter grades for the strength of scientific evidence, similar to grades used in school. A “B” grade indicates there is at least a moderate certainty that the net benefit is moderate to substantial, and the USPSTF recommends that the service is offered in practice.)

These types of programs are typically structured as regular visits to help kids learn new skills. The programs include specific behavioral elements such as self-monitoring, goal-setting and problem-solving. They address behaviors related to obesity, including physical activity, nutrition and screen time.

The evidence is strongest for programs that have 26 hours or more of contact and include physical activity. That amount, 26 hours, may seem arbitrary, but it’s often structured as at least an hour a week for six months, long enough to support and reinforce new behaviors over time. The Stanford program is designed as 90-minute sessions each week for six months and includes both children and their parents or other caregivers. Generally, the more effective programs target both parents and kids.

Why is it important to include both parents and children in pediatric weight management programs, and what is the best way to do so?

You need parents to be supportive of changes the kids are making, even if, as in our program, you focus on the children as their own change agents. Children live in the context of families, and their parents have so much control over what resources they have: nutritious foods, physical activity opportunities, screen time.

But children need to be motivated to make changes themselves. Otherwise it’s them versus the parents. We believe it works better when the parents are supportive of goals that the child is making, as opposed to the parent coming up with the goals themselves and then “policing” the child’s behavior or choices.

In our program, we encourage kids and parents to meet every night to review their journals (of their eating, physical activity and screen behaviors) and goals, but we don’t want the parent to fill out the journal; we want them to help the child succeed in doing that for themselves. We want the children and parents to set appropriate goals together: How much should I try to reduce my “red-light” foods, how much should I try to increase my physical activity this week, knowing that, OK, how many birthday parties are there this week? How many school events? Are we going to have time to do that?

We also encourage kids and parents to explain the importance of the program to everyone in the family, “We’re doing this as a family, to get healthier as a family” so that one child does not feel singled out and others don’t feel punished, and to help deal with challenges like grandparents who might want to “spoil” their grandkids with treats.

Comprehensive, intensive behavioral programs have been recommended by the US Preventive Services task force for pediatric weight loss since 2010, but these programs can be difficult to find. Why is that?

Partly because these programs don’t fit the standard doctor-patient, single-visit or periodic-visit, acute-care medical model. But even more important, because there is almost no reimbursement for them. Reimbursement and funding of these programs tend to be local, and patchy. Our program is primarily supported by Stanford Medicine Children’s Health, through the community benefits program, through our children’s hospital’s financial aid system for people who can’t afford it, and out-of-pocket for families who can afford it. We’ve also had several grants from local foundations in the past. But that type of support doesn’t exist in every community.

We have done a lot of work to try to make our Pediatric Weight Control Program model more widely available. Over the years, we’ve gone to plenty of medical plans and talked to their decision makers, and there has been a lot of resistance to paying for a program that fits this intensive behavioral model. Part of the problem is that, from a health insurer’s perspective, the costs of obesity accumulate over a lifetime. While they won’t necessarily admit it, they prefer not to pay now to help a child prevent a problem that is mostly going to cause medical expenses years from now when they might be covered by a different insurer. We’ve also talked to employers’ benefit plans, but we’ve not found much appetite among employers for adding services for employees’ dependents, even though they offer dependent health insurance.

Because reimbursement isn’t consistently available, comprehensive, intensive pediatric weight management programs exist in only a handful of communities in the entire US.  There is real inequity in families’ ability to access this treatment that has been recommended for nearly 15 years.

What did the task force say about other treatments, such as new drugs or bariatric surgery?

The US Preventive Services Task Force reviewed the data on new obesity medications. Because the number of studies for all drugs were small, particularly for the two drugs that are most effective (semaglutide and liraglutide), they concluded that the data are inadequate to make a recommendation. The drugs have FDA approval for treating obesity for those over 12, but the task force requires more studies to recommend something for all primary care. Weight loss surgery was not included in the USPSTF evidence review.

It’s worth noting that the American Academy of Pediatrics recently took a different recommendation approach. After their own evidence reviews, the AAP said that because comprehensive, intensive lifestyle programs don’t exist in many places, and are hard to get reimbursed for even where they do exist, pediatricians can consider using medications and bariatric surgery for adolescents with severe obesity.

There’s a lot of excitement about the newer weight loss drugs because we’ve been hoping for effective obesity medications for many years. One can make a pretty good case for using these medications in children and adolescents who are experiencing negative effects from their obesity, with the caveat that there is a lot we don’t know about them. The US Preventive Services Task Force listed gaps in the scientific evidence that need to be filled, such as risks and benefits of longer-term use and how they should be integrated with other treatments like diet and physical activity changes.

The main mechanism of these drugs is to dramatically reduce food intake, but they don’t all of a sudden make you want to eat more fruits and vegetables and become more physically active – behaviors that have their own benefits beyond weight. If you’re eating less and it’s mostly unhealthy food, what does that do to your nutritional health?

We also don’t know the long-term impacts of these drugs on teens who are continuing to develop their brains and bodies; teens are not the same as adults. When you lose weight, you lose muscle mass, too. How does that affect your bone and muscle development while you’re growing? In addition, we don’t know the effects of the drugs themselves long-term. Will people be able to go off the drugs for a while and then go back on, or will they need to keep taking them for the rest of their lives? I am also concerned that the success of these medications will distract attention away from changing the social and physical environments that are the causes of the obesity epidemic.

How do we address pediatric obesity without shaming kids or worsening their body image?

We know there’s a tremendous amount of stigma and discrimination associated with obesity – from individuals and from society as a whole. Many children with obesity are teased and harassed, and sometimes blame themselves. Parents can also feel blamed or judged and blame themselves if they have a child with obesity. Because of the stigma, it takes a lot for patients and families to seek medical care. All health professionals need to be very sensitive to that.

At the very least, we try to use thoughtful language. This includes using people-first language: saying “a child with overweight” not “an overweight child,” for example, because we don’t want to define a person by their disease. When we’re working with families, we try to let them come up with the language they want to use. It is not the same for every family. Some families are comfortable using the word “fat” and others would never use that word, for instance. Some might say “big boned” or “heavy for their age.” 

We also try to focus blame on the environments we live in that make it very difficult to control one’s weight. There is so much we need to do at a societal level to address the factors driving obesity. Obesity is not due to a lack of willpower. We saw very low rates of obesity in children and adults before the 1980’s – the world didn’t experience a sudden loss of willpower in 1980.

We want people to feel they have power to make changes and help themselves get healthier. But we also need to say that even if your genes make you more susceptible to our environment — a broken food system which provides cheap, high-calorie, super-tasty, heavily marketed food everywhere, and transportation, media, technology and community design that make so much of our lives sedentary — this is not your fault. We need to use public health policy to address the true causes. But there are also things you can do to fight back by adopting the more healthful strategies we help you learn.

It is important to note that participants in our Pediatric Weight Control Program report significant reductions in depressive symptoms and increases in self-esteem. We also systematically measure risk for eating disorders and have not found increases. This has also been found in meta-analyses of behavioral weight control programs for children and was highlighted in both the USPSTF report and the AAP guidelines.

Some of your research has focused on how to make obesity treatment more equitable. How should we be doing that?

Obesity among kids and teens isn’t equally distributed across the U.S. It’s more of a problem among low-income and racial and ethnic minority populations, who are more likely to live in environments that are more obesity-promoting. Like we say, “Your Zip code matters more than your genetic code.”

Since 2010, the US Preventive Services Task Force has recommended comprehensive, intensive behavioral interventions for pediatric obesity. The American Academy of Pediatrics and the U.S. Centers for Disease Control and Prevention also recommend these programs. But because they’re not widely covered by health insurance, access to these recommended obesity treatment programs is very inequitable. There is a great need for medical care organizations and insurers to finally catch up with the recommendations and make these programs widely available.

We studied taking many of the components of our program from the clinic setting to community settings for low-income Latino families – right into their homes and neighborhood community centers – and have shown this can work. We need more ways to deliver effective interventions in settings where children and families already live, learn and play.

Also, with funding from the CDC, we have almost completed developing a first-of-its-kind, online, comprehensive platform to provide everything needed for any health care practice, hospital, public health agency, medical insurer, employer, or youth-serving community organization to deliver our comprehensive, intensive Pediatric Weight Control Program for their own patients and community. Our goal is to make safe and effective weight control more feasible, cost-effective and equitably available for all children with obesity in every community in the US.

But the most important way to address the inequity is with better public policy, to change our toxic environment that preys unequally on different population groups.

 Originally published on the Stanford Medicine Scope


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